Provider Demographics
NPI:1821418856
Name:RUSSO, LINDSEY
Entity Type:Individual
Prefix:
First Name:LINDSEY
Middle Name:
Last Name:RUSSO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5163 ROSWELL RD
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30342-2206
Mailing Address - Country:US
Mailing Address - Phone:877-288-4760
Mailing Address - Fax:
Practice Address - Street 1:5163 ROSWELL RD
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30342-2206
Practice Address - Country:US
Practice Address - Phone:877-288-4760
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-17
Last Update Date:2021-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X, 222Q00000X
GA1-21-55559103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist